1. Delivering Treatment for Depression into the Patient’s Home: Telephone & Internet David C. Mohr, Ph.D. Northwestern University & Center for the Management of Complex Chronic Care Hines VA

2. What I will talk about today Describe our telephone psychotherapy research program in depression. Describe our telephone psychotherapy research program in depression. We began in 1995, when the telephone was the principal option for reaching out We began in 1995, when the telephone was the principal option for reaching out Current state of internet treatments for depression Current state of internet treatments for depression Our developing research in integrating internet and telephone. Our developing research in integrating internet and telephone.

3. Telephones in Psychotherapy In 1876 Alexander Graham Bell invented the telephone In 1876 Alexander Graham Bell invented the telephone Three years later, in 1879, BMJ published the first report of a the use of a telephone to diagnose a child’s cough. Three years later, in 1879, BMJ published the first report of a the use of a telephone to diagnose a child’s cough. Another 70 years was required before the first reports of the use of telephones in psychotherapy were published (1949). Another 70 years was required before the first reports of the use of telephones in psychotherapy were published (1949). A 1996 APA task force report stated that empirical evidence of the efficacy of telphone-administered psychotherapy was scant to non-existent. A 1996 APA task force report stated that empirical evidence of the efficacy of telphone-administered psychotherapy was scant to non-existent.

4. Why look at telephone psychotherapy? Nearly 2/3rds of practicing clinical psychologists today report using the phone to some degree to deliver care. Nearly 2/3rds of practicing clinical psychologists today report using the phone to some degree to deliver care. Mental Health carve-outs, HMOs, the VA and others are beginning to develop and implement tele-mental health programs to Mental Health carve-outs, HMOs, the VA and others are beginning to develop and implement tele-mental health programs to Extend care Extend care Save costs Save costs Research to develop and validate tele-mental health programs would Research to develop and validate tele-mental health programs would Facilitate policy decision making Facilitate policy decision making Support standards for quality Support standards for quality

5. How we began We began in 1995, when the telephone was the principal tool for outreach We began in 1995, when the telephone was the principal tool for outreach Many patients at the UCSF Multiple Sclerosis Center were unable to attend regularly scheduled appointments due to Many patients at the UCSF Multiple Sclerosis Center were unable to attend regularly scheduled appointments due to Disability Disability Distance from center Distance from center Two-thirds of patients would prefer psychotherapy or counseling to pharmacotherapy. Two-thirds of patients would prefer psychotherapy or counseling to pharmacotherapy.

6. Initial Pilot Research We developed a telephone-administered cognitive behavioral therapy (T-CBT) that includes: We developed a telephone-administered cognitive behavioral therapy (T-CBT) that includes: A patient workbook to A patient workbook to facilitate communication facilitate communication provide information provide information provide support between sessions. provide support between sessions. 32 Kaiser multiple sclerosis patients with POMS depression > 15 were randomly assigned to: 32 Kaiser multiple sclerosis patients with POMS depression > 15 were randomly assigned to: 8 weeks of T-CBT administered by 2 nd -3 rd year graduate students. 8 weeks of T-CBT administered by 2 nd -3 rd year graduate students. Usual care control (UCC) through Kaiser Permanente Usual care control (UCC) through Kaiser Permanente

7. Mohr, D.C. et al., J Clin Conult Psychology. 2005;68:356-361

8. T-CBT vs. T-SEFT Compared 16 weeks of T-CBT to T-Supportive Emotion-Focused Therapy (T-SEFT). Compared 16 weeks of T-CBT to T-Supportive Emotion-Focused Therapy (T-SEFT). T-SEFT a manualized, client centered tx, aimed at enhancing awareness of emotions and inner experience, with operationalized procedures for enhancing therapeutic relationship. Interventions focused on behavior or cognition were prohibited. T-SEFT a manualized, client centered tx, aimed at enhancing awareness of emotions and inner experience, with operationalized procedures for enhancing therapeutic relationship. Interventions focused on behavior or cognition were prohibited. 127 Patients were randomized: 127 Patients were randomized: MS MS BDI ≥ 16 BDI ≥ 16 1+ physical symptoms causing participation restriction (handicap) 1+ physical symptoms causing participation restriction (handicap) 99 (77%) women 99 (77%) women Therapists were Ph.D psychologists, with allegiance to their treatment arm. Therapists were Ph.D psychologists, with allegiance to their treatment arm. Supervisors were specialists in CBT and SEFT Supervisors were specialists in CBT and SEFT Patients were followed for one year after treatment cessation Patients were followed for one year after treatment cessation

9. Mohr, D.C. et al., Arch Gen Psychaitr. 2005;62:1007-1014

13. T-CBT vs. T-SEFT A large literature has shown most psychotherapies are equivalent in reducing depression. A large literature has shown most psychotherapies are equivalent in reducing depression. CBT and SEFT, face-to-face, have been shown to be equivalent in face-to-face administration (Watson et al. JCCP 2003;71:773-81) CBT and SEFT, face-to-face, have been shown to be equivalent in face-to-face administration (Watson et al. JCCP 2003;71:773-81) Our finding that T-CBT is superior suggests that this this may not be true with tele-therapy to patients with barriers. Our finding that T-CBT is superior suggests that this this may not be true with tele-therapy to patients with barriers. Skills training is important! Skills training is important!

14. Attrition Attrition in trials of face-to-face psychotherapy ranges from 15-60% with a means of 26% to 47% Attrition in trials of face-to-face psychotherapy ranges from 15-60% with a means of 26% to 47% Attrition was 7 (5.5%) Attrition was 7 (5.5%) 3 (4.8%) for T-CBT 3 (4.8%) for T-CBT One was removed secondary to trauma. One was removed secondary to trauma. 4 (6.2%) for T-SEFT 4 (6.2%) for T-SEFT

16. Barriers to Psychotherapy in Primary Care Primary care is the de facto site for identification and treatment of depression. Primary care is the de facto site for identification and treatment of depression. Approximately 2/3rds of depressed patients state that they would prefer psychotherapy to antidepressant medications. But… Approximately 2/3rds of depressed patients state that they would prefer psychotherapy to antidepressant medications. But… Only approximately 20% follow-up on referrals by their primary care physician. Only approximately 20% follow-up on referrals by their primary care physician. Of those who begin nearly half dropout of treatment. Of those who begin nearly half dropout of treatment. This suggests that there are significant barriers to psychotherapy. This suggests that there are significant barriers to psychotherapy.

17. Barriers to Psychotherapy in 290 UCSF Primary Care patients Depressed patients are more likely to perceive barriers (74.0% vs. 51.4%, p=.0002) Depressed patients are more likely to perceive barriers (74.0% vs. 51.4%, p=.0002) Among depressed patients 68.3% report practical barriers including Among depressed patients 68.3% report practical barriers including Transportation (21.2%) Transportation (21.2%) Time constraints (20.6%) Time constraints (20.6%) Caregiving responsibilities (13.6%) Caregiving responsibilities (13.6%) 19.2% report emotional barriers including 19.2% report emotional barriers including Concerns about being seen while emotional (6.8%) Concerns about being seen while emotional (6.8%) People finding out they are in psychotherapy (6.8%) People finding out they are in psychotherapy (6.8%)

18. Depression is both a indication for psychotherapy and a barrier to receiving it. Depression is both a indication for psychotherapy and a barrier to receiving it. Inserting behavioral medicine into primary care has not been widely adopted. Inserting behavioral medicine into primary care has not been widely adopted. Data suggest T-CBT may increase access for and reduce attrition from psychotherapy for depression. Data suggest T-CBT may increase access for and reduce attrition from psychotherapy for depression. A current trial is examining T-CBT for the treatment of depression in veterans in rural areas with limited mental health services. A current trial is examining T-CBT for the treatment of depression in veterans in rural areas with limited mental health services. A randomized trial of T-CBT compared to face-to-face CBT for depression in primary care has been funded by the NIMH and will begin in the coming months. A randomized trial of T-CBT compared to face-to-face CBT for depression in primary care has been funded by the NIMH and will begin in the coming months. And so, can we reach out?

19. Telecommunications innovations since 1995 Internet penetration Internet penetration 73% of Americans have internet access (compared to 95% with telephone access). 73% of Americans have internet access (compared to 95% with telephone access). 42% have broadband access (40% increase in one year). 42% have broadband access (40% increase in one year). Access is much higher in urban areas Access is much higher in urban areas Promise of Internet CBT Promise of Internet CBT Standardized presentation of therapy material Standardized presentation of therapy material Interactive programming for exercises Interactive programming for exercises No geographic limitations to services. No geographic limitations to services. Patient access 24/7 Patient access 24/7 Costs are potentially minimal Costs are potentially minimal Multiple avenues for contact with therapist Multiple avenues for contact with therapist

20. Why should we be worried about standardization of content? RCT data shows CBT is largely equivalent to antidepressant medication. RCT data shows CBT is largely equivalent to antidepressant medication. Among 6,047 pts treated with psychotherapy in HMOs, CMHCs, EAPs etc. (Hansen 2002,2003) Among 6,047 pts treated with psychotherapy in HMOs, CMHCs, EAPs etc. (Hansen 2002,2003) 8.2% deteriorated 8.2% deteriorated 56.8% showed no change 56.8% showed no change 20.9% showed some measurable improvement 20.9% showed some measurable improvement 14.1% met criteria for recovery 14.1% met criteria for recovery After 16 sessions, only 50% of patients show measurable improvement. After 16 sessions, only 50% of patients show measurable improvement.

21. Why are psychotherapy outcomes so bad in the community, compared to RCTs Patients in the community may be more difficult than those selected for clinical trials. Patients in the community may be more difficult than those selected for clinical trials. Multiple psychiatric problems, substance abuse, etc. Multiple psychiatric problems, substance abuse, etc. But RCTs rule most people out for not being severe enough. But RCTs rule most people out for not being severe enough. Assuring competence in a private endeavor Assuring competence in a private endeavor Evidence that adherence to tx model improves outcomes. Evidence that adherence to tx model improves outcomes. Even in RCTs at least 25% of sessions do not meet criteria. Even in RCTs at least 25% of sessions do not meet criteria. Nobody knows what therapists in the community do. Nobody knows what therapists in the community do.

22. I-CBT Opportunity to provide standardized care Opportunity to provide standardized care Provide over a long distance Provide over a long distance At minimal cost. At minimal cost.

24. Clarke, 2002 Cont’d Potential reasons for failure Potential reasons for failure Low compliance with website: Low compliance with website: Median visits = 2 Median visits = 2 Mean visits = 2.6 ± 3.5 Mean visits = 2.6 ± 3.5 Attrition Attrition 34.4% across both treatments 34.4% across both treatments

26. Clarke, 2005 cont’d Compliance somewhat better but not great: Compliance somewhat better but not great: I-CBT+postcard: M = 5.0±6.2 I-CBT+postcard: M = 5.0±6.2 I-CBT+telephone call: M = 5.6±5.8 I-CBT+telephone call: M = 5.6±5.8 TAU (+I-CBT access): M = 2.6±2.5 TAU (+I-CBT access): M = 2.6±2.5 Attrition still not good Attrition still not good I-CBT+postcard: 38.7% I-CBT+postcard: 38.7% I-CBT+telephone call: M = 46.3% I-CBT+telephone call: M = 46.3% TAU: 20.0% TAU: 20.0%

28. Christensen, 2005 Cont’d Compliance Compliance I-CBT + Lay phone calls: M = 14.8±9.7 of 29 exercises I-CBT + Lay phone calls: M = 14.8±9.7 of 29 exercises Internet information: M = 4.5±1.4 visits Internet information: M = 4.5±1.4 visits Attrition Attrition I-CBT + Lay phone calls: 33.5% I-CBT + Lay phone calls: 33.5% Internet information: 17.6% Internet information: 17.6% No treatment control: 11.8% No treatment control: 11.8%

29. Problems with I-CBT Assignment to I-CBT associated with greater dropout than no-tx or TAU. Assignment to I-CBT associated with greater dropout than no-tx or TAU. People aren’t using it. People aren’t using it. 34-47% of I-CBT patients drop out. 34-47% of I-CBT patients drop out. 2-6 visits 2-6 visits Phone calls from lay persons don’t help much Phone calls from lay persons don’t help much I-CBT sites to date have not been tailored to the patient. I-CBT sites to date have not been tailored to the patient.

31. Strengths & Weakness Telephone-Psychotherapy (T-CBT) Telephone-Psychotherapy (T-CBT) + Low attrition (<5%) + Strong efficacy under controlled conditions + Excellent outreach / reduction in barriers - Relies on therapist adherence to tx model - No significant cost savings I-CBT I-CBT + Standardized presentation of material + Geographic coverage, 24/7 coverage + Minimal cost - Effect sizes appear much lower than other treatments - Attrition high (comparable to face-to-face therapy) - Compliance (visiting site) is low.

32. One hour of Psychotherapy per week Psychotherapy ψψ

33. Or….. Brief T-CBT ψψ Web HW e-mail Brief Telephone Coaching Web Class

34. Telephone administered psychotherapy is effective in treating depression. Telephone administered psychotherapy is effective in treating depression. The inclusion of CBT skills training components add benefit during 16 weeks of treatment. The inclusion of CBT skills training components add benefit during 16 weeks of treatment. These skills may be taught more efficiently using tele-communications technology that brings training into patients’ lives. These skills may be taught more efficiently using tele-communications technology that brings training into patients’ lives. Future research: Future research: Compare telephone administered psychotherapy to face-to-face administered psychotherapy Compare telephone administered psychotherapy to face-to-face administered psychotherapy Evaluate new procedures for integrating treatment into patients’ lives using internet and other telecommunications technologies. Evaluate new procedures for integrating treatment into patients’ lives using internet and other telecommunications technologies.Conclusions